Russian Medical Massage: Massage for Carpal Tunnel Syndrome

Carpal tunnel syndrome falls into the category of peripheral neuropathy -- a dysfunction of a single nerve that produces a variety of neurological and general symptoms, such as pain, muscle weakness and atrophy, vasomotor problems (which affect the caliber of the blood vessels), and sensory loss.

Carpal tunnel syndrome results from compression on the median nerve by the structures that surround it. In order for us to understand the cause of this dysfunction we have to take a closer look at the structure in which this dysfunction occurs.

The carpal tunnel

The tunnel through which the median nerve runs is created by the flexor retinaculum, or transverse carpal ligament, and the carpal bones. The canal is created for the flexor tendons, which lie directly beneath the median nerve, and for the median nerve itself to run through. The median nerve supplies five muscles in the hand, which are found in the index, middle and fourth fingers, and in the thumb. The median nerve, being one of the brachial plexus nerves (it originates at the C6-T1), runs through the medial side (inside) of the arm, through the medial part of the elbow and ends at the above-mentioned fingers. It is a sensory nerve and provides innervation for most flexors of the forearm, elbow joint, and many joints of the hand, thumb muscles and skin of the hand. Another structural aspect that makes the median nerve so very prone to involvement is its makeup: it is created from large-diameter fibers that will react to even slight pressure. The wrist is not designed for repetitive tasks or for heavy use, because it is made from fine structures that were intended for fine motor use. The wrist is prone to dysfunction if it is required to perform functions for which it is not built.

Now that we have painted a picture of the structure we are dealing with, let's examine how carpal tunnel syndrome occurs.

Causes of carpal tunnel syndrome

Carpal tunnel syndrome results from compression on the median nerve by the surrounding structures, or by changes that occur in the tunnel itself. Seldom will we see carpal tunnel syndrome develop due to a single injury to the wrist. More often it occurs due to continuous overuse of the wrist while performing a repetitive activity -also known as cumulative trauma disorder.

Carpal tunnel syndrome is one of the fastest growing dysfunctions affecting the American population today. Between 14 and 18 million people suffer from cumulative trauma disorders every year, according to CDTNEWS, and of these close to two million individuals suffer from carpal tunnel syndrome. Also according to CDTNEWS, 4.4 million injuries are attributable to computer keyboard use.

The growth of reported cumulative trauma disorder in the workplace has increased 1,300 percent in the past 12 years. The cost for surgery to treat carpal tunnel syndrome reached $29,900 in 1990; but the cost of treatment is not the main issue. More than 39 percent of those injured had to miss more than a month of work due to this condition, and often these people had to find another type of job in order to avoid repeated trauma. Many types of activities can contribute to carpal tunnel syndrome, including typing/data entry, tool use, grasping objects repetitively, using a sewing machine, repairing precision instruments, assembling, operating machinery, construction, house painting, meat wrapping and gardening. Improper use of wrists and hands, and overuse of the thumbs while giving massage can also lead to the development of carpal tunnel syndrome.

The motion of repeated forceful wrist flexion is the common ground for all of the above-listed activities, and since the wrist is not designed to be used this way, most often forearm muscles and wrist tendons become overused and strained. This leads to contraction of the muscles and tendons, as well as swelling of these structures, which in turn produces pressure on the median nerve.

Other conditions that contribute to carpal tunnel syndrome include diabetes, Guillain Barre syndrome, rheumatoid arthritis and pregnancy. These conditions contribute to the syndrome by increasing fluid in the tissue -- especially in the extremities; and secondary production of deposits in the limited spaces -- such as the carpal tunnel. People who use the motion of pronation repetitively may affect the median nerve at the elbow, which can cause its irritation and produce symptoms associated with carpal tunnel syndrome -- and which can later lead to the development ofcarpal tunnel syndrome. Whatever the reason for the median nerve compression, the symptoms of carpal tunnel syndrome will cause a significant amount of pain and often total disability. The following are the symptoms clients with carpal tunnel syndrome often complain about:

Numb or cold fingers, tingling and burning sensations (also known as paresthesia) of the thumb, index, middle and ring fingers. Often, clients wake up at night due to the above-described sensations;
Sensory deficit in the radial-palmar aspect of the hand;
Pain in the wrist, palm and/or forearm that worsens at night; and
Weakness and atrophy of the thumb abductors.
Russian Medical Massage

Although the pain originates at the wrist, it can radiate to the elbow and even the shoulder by traveling along the passage of the median nerve; it can be temporarily relieved by shaking out the hands. Although today there are complex nerve conduction tests that can be performed to determine the condition of the median nerve, two simple tests can be done to see if the median nerve is involved. They are: Tinel's test (tapping over the median nerve at the wrist and receiving paresthesia in the fingers innervated by the nerve); and determining if the client can oppose his or her thumb without pain. (Note: make sure the client has been pre-diagnosed by a physician as having carpal tunnel syndrome before applying tests or treatment).

Standard treatment

Allopathic treatment consists of splinting the forearm/wrist, especially during the night, and surgery. Surgical procedure involves sectioning, or cutting, the transverse carpal ligament in order to decompress the nerve. Certain complications can result from surgery -- mainly scar tissue formation in the sectioned ligament, which once again will produce compression on the median nerve. In fact, the Journal of Hand Surgery reported that in a study of 60 patients, only 27 percent reported a good outcome from surgery, whereas 32 percent stated that the symptoms persisted or worsened (42 percent considered the symptoms mostly improved).

A couple of years ago I had the chance to work with Dr. Mitchell Mally, one of the leaders in the chiropractic field's treatment of carpal tunnel syndrome. Mally manipulates the wrist so that the carpal bones, which are involved and often contribute to the compression on the median nerve, are repositioned correctly. By setting the bones in their correct places, the chiropractor enlarges the size of the carpal tunnel and eliminates the compression on the median nerve. This treatment seems to be very effective, and is quickly becoming one of the standards of carpal tunnel syndrome treatment protocol. Often ultrasound is used along with manipulation, which provides additional relief to chiropractic patients.

Massage treatment

Massage treatment goals for carpal tunnel syndrome will differ from one client to another according to the severity of the condition and symptoms that are present. Massage treatment goals are to:

Decrease edema at the wrist;
Decrease muscle contraction of the forearm flexors;
Decrease tension of the wrist flexor tendons;
Increase elasticity of the tendons that compress on the median nerve;
Break up and eliminate pathological deposits (if edema was present but is currently absent);
If post-surgical, increase elasticity of the transverse ligament scar;
Decrease irritation of the median nerve;
Decrease pain and paresthesia (numbness, tingling, burning, cold sensations); and
Normalize muscle tone and strength of the forearm and thumb.
Russian massage techniques can accomplish all of these goals. It was mentioned earlier that swelling is one of the conditions that not only accompanies carpal tunnel syndrome, but also contributes to nerve compression. By decreasing edema in the wrist you will not only decrease pain, but will also prevent development of the pathological deposits in the carpal tunnel. Once edema is dealt with (or in case of its absence) you can progress to the other goals.

Whenever nerve pain is present, progress your work from the area of least pain to the most painful area, along the passage of the nerve. In the case of carpal tunnel syndrome, begin on the forearm and progress into the wrist. Divide the forearm into two parts, starting at the bulk of the forearm flexors (closer to the elbow), and after a few strokes of clasping effleurage begin gentle friction with fingers. Your massage should be painless, and your progression to the deep friction strokes -- such as crestlng friction and friction with the heel of the hand -- will depend on the clients' ability to receive them. Friction should originate in the proximal area moving distally (toward the hand) and should stop halfway down. This friction increases pliability of the muscle and will also calm the nerve. The client should report a decrease of pain in the wrist and fingers before you move to the next half of the forearm.

Another stroke that calms the median nerve is gentle vibration. Place all four fingers in the area of the nerve projection and move your hand side to side, to create a shaking movement. Progress downward in the distal direction. Use a few strokes of friction followed by a few strokes of vibration and then repeat the combination (rather than friction for a prolonged period of time and then vibration for a period of time). On the second half of the forearm you will continue with the same treatment as described above, but you will more likely use friction with fingers more than any other form of friction.

Once again, do not fight the tissue, but repeat your friction and vibration combinations until the client reports a decrease of pain and you feel increased pliability of the tendons. This progression to the next area might take a few treatments to accomplish -- remember to be guided by the client's ability to receive rather than this protocol. As the client's tissue continues to respond, you should see progressive improvement in the muscle's pliability. This will allow you to spend less time on that area and more time on the more distal area. In a few treatments (it will vary from client to client depending on the severity of the condition) you should be able to progress to the wrist. Before any treatment is done on the wrist itself, make sure that there is no swelling (if edema is present use the strokes of effleurage above it to resolve this edema).

On the wrist itself, start with very superficial friction with fingers combined with vibration. After a few minutes of the treatment move on to more proximal areas with the massage being done on that area, and work there for a few minutes before returning to the area of the wrist. A note of caution: whenever working with the irritated nerve you are walking a very thin line between decreasing irritation of that nerve and actually causing more irritation. It is better to underwork the irritated nerve than to overwork it. As the client progresses through the treatments Ire or she should report the following improvements: less paresthesia occurring in the fingers; a significant decrease of pain in the forearm and wrist; and the ability to resume some of the activities required the use of the forearm, wrist and hand.

As nerve irritation decreases, progress to the final stage of your treatment in order to increase elasticity of the wrist tendons and ligaments, and prevent compression on the nerve in the future. Deeper friction with fingers and hatching friction is used to accomplish this goal. Please remember that pain should be completely absent before graduating to deeper treatment. At that time you may also want to include friction of the thumb and encourage the patient to begin an exercise program to strengthen his or her wrist and hand flexors (Theraband and Theraputty exercises are standard for accomplishing this goal).

The treatment schedule is done every day for 10-15 minutes per treatment. Depending on his or her condition, the client may be seen 12-15 times. If more treatments are needed to accomplish the above-listed goals, wait at least 10 days before resuming the next set of treatments.